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Casipit BA, Lo KB, Casipit CG, Idowu A, Amanullah A. Impact of comorbid heart failure among hospitalized patients with sarcoidosis: A United States population-based cohort study. IJC HEART & VASCULATURE 2023; 49:101275. [PMID: 37822667 PMCID: PMC10562780 DOI: 10.1016/j.ijcha.2023.101275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/05/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Abstract
Background There is paucity of data regarding the impact of concomitant heart failure (HF) on the in-hospital outcomes among hospitalized sarcoidosis patients. We aim to investigate the factors associated with concomitant HF and its impact on in-hospital outcomes among hospitalized sarcoidosis patients. Methods We utilized the 2018-2020 National Inpatient Sample (NIS) Database in conducting this study. Multivariable logistic and linear regression models were used to examine the factors associated with HF and hospital-associated outcomes among patients with sarcoidosis. Results A total of 36,864 hospitalized patients with sarcoidosis were identified, of which 24.78 % (n = 9135/36,864) had concomitant HF. Factors associated with concomitant HF were age (aOR 1.03; 95 % CI: 1.02-1.03, p value ≤ 0.001), black race (aOR 1.74; 95 % CI: 1.47-2.05, p value ≤ 0.001), not being female (aOR 0.79; 95 % CI: 0.69-0.91, p value ≤ 0.001), and arrhythmias (aOR 2.50; 95 % CI: 2.10-2.98, p value ≤ 0.001) specifically atrial fibrillation and ventricular tachycardia. Comorbidities associated with concomitant HF in this population were hyperlipidemia, obesity, coronary artery disease, cardiac device implantation history, and chronic kidney disease stage 1-4. Concomitant HF was not an independent predictor of in-hospital mortality or length of stay (LOS). However, age (aOR 1.04; 95 % CI, 1.03-1.06; p ≤ 0.001) and arrhythmia burden (aOR 2.08; 95 % CI, 1.47-2.95; p ≤ 0.001), specifically ventricular tachycardia and fibrillation, were independently associated with in-hospital mortality among sarcoidosis patients. Conclusion Traditional cardiovascular risk factors were associated with concomitant HF among hospitalized sarcoidosis patients. Moreover, concomitant HF among sarcoidosis patients was not significantly associated with in-hospital mortality or LOS.
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Affiliation(s)
- Bruce Adrian Casipit
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - Abdiodun Idowu
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Aman Amanullah
- Department of Cardiovascular Disease, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
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2
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Dai Q, Sherif AA, Jin C, Chen Y, Cai P, Li P. Machine learning predicting mortality in sarcoidosis patients admitted for acute heart failure. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2022; 3:297-304. [PMID: 36589310 PMCID: PMC9795270 DOI: 10.1016/j.cvdhj.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Sarcoidosis with cardiac involvement, although rare, has a worse prognosis than sarcoidosis involving other organ systems. Objective We used a large dataset to train machine learning models to predict in-hospital mortality among sarcoidosis patients admitted with heart failure (HF). Method Utilizing the National Inpatient Sample, we identified 4659 patients hospitalized with a primary diagnosis of HF. In this cohort, we identified patients with a secondary diagnosis of sarcoidosis using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes. Patients were separated into a training group and a testing group in a 7:3 ratio. Least absolute shrinkage and selection operator regression was used to select variables to prevent model overfitting or underfitting. For machine learning models, logistic regression, random forest, and XGBoosting were applied in the training group. Parameters in each of the models were tuned using the GridSearchCV function. After training, all models were further validated in the testing group. Models were then evaluated using the area under curve (AUC) score, sensitivity, and specificity. Results A total of 2.3% of sarcoidosis patients died in HF admission. Our machine learning model analysis found the RF model to have the highest AUC score and sensitivity. Feature analysis found that comorbid arrhythmias and fluid electrolyte disorders were the strongest factors in predicting in-hospital mortality. Conclusion Machine learning methods can be useful in identifying predictors of in-hospital mortality in a given dataset.
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Affiliation(s)
- Qiying Dai
- Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Akil A. Sherif
- Division of Cardiology, Saint Vincent Hospital, Worcester, Massachusetts
| | - Chengyue Jin
- Division of Cardiology, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Yongbin Chen
- Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
| | - Peng Cai
- Department of Mathematical Sciences, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia,Address reprint requests and correspondence: Dr Pengyang Li, Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA 23219.
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3
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Voronkova OO, Tsvetkova OA, Avdeev SN, Rogova EF, Abdullaeva GB. [Sarcoidosis with Cardiac Involvement and Monoclonal Gammopathy]. ACTA ACUST UNITED AC 2020; 60:151-156. [PMID: 32394870 DOI: 10.18087/cardio.2020.4.n712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 02/03/2020] [Accepted: 02/17/2020] [Indexed: 11/18/2022]
Abstract
The article presented a clinical case of 8-year follow-up of a patient with a relatively beneficial course of pulmonary sarcoidosis and intrathoracic lymph nodes and with gradually progressing myocardial injury. A specific feature of the case was that the patient had monoclonal gammopathy, which is extremely rarely reported. Morphological signs of paraproteinemic hemoblastosis and amyloidosis were not observed. The article considered a whole complex of studies, which is required for diagnosing cardiac sarcoidosis in a specific patient and addressed the issue of monoclonal gammopathy origination.
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Affiliation(s)
- O O Voronkova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O A Tsvetkova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - S N Avdeev
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E F Rogova
- pulmonology Department University Clinical hospital 1 I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - G B Abdullaeva
- pulmonology Department University Clinical hospital 1 I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Roth D, Kadoglou N, Leeflang M, Spijker R, Herkner H, Trivella M. Diagnostic accuracy of cardiac MRI, FDG-PET, and myocardial biopsy for the diagnosis of cardiac sarcoidosis: a protocol for a systematic review and meta-analysis. Diagn Progn Res 2020; 4:5. [PMID: 32399494 PMCID: PMC7204224 DOI: 10.1186/s41512-020-00073-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/16/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND CS constitutes a rare but potentially underdiagnosed and fatal disease. Its diagnosis remains difficult owing to the infrequent and indistinguishable symptoms and the lack of formal diagnostic criteria dependent upon the diagnostic techniques used. Early diagnosis and treatment, however, may help to counter its poor prognosis.We aim to characterize and compare the diagnostic accuracy of cardiac MRI, FDG-PET and myocardial biopsy for the diagnosis of cardiac sarcoidosis and to advance and compare methods for complex diagnostic test accuracy reviews and meta-analysis. METHODS Following a systematic review on DTA studies on the aforementioned topic, a four-part approach to meta-analysis will be used: (1) direct comparison of index tests with clinical reference standard, (2) indirect comparison of index tests with clinical reference standard, (3) addition of an alternative test to that indirect comparison (4) and Bayesian meta-analysis using results of part 3 as informative prior for comparisons analogous to part 1 and 2. DISCUSSION The most widely recognized diagnostic algorithm for cardiac sarcoidosis is considered out of date, as it precedes the introduction of imaging techniques in diagnostic pathways. These novel imaging techniques, like CMR and FDG-PET scan, have emerged as promising diagnostic tools which may fill the current diagnostic gap. Thus, a systematic review and evaluation of CS diagnosis are much needed. Such an attempt is anticipated to alter the current diagnostic guidelines for CS by shedding more light on the role of sophisticated imaging techniques on prompt CS therapy and follow-up. TRIAL REGISTRATION PROSPERO, CRD42019047126.
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Affiliation(s)
- Dominik Roth
- grid.4991.50000 0004 1936 8948Centre for Statistics in Medicine, NDORMS, University of Oxford, Windmill Road, Oxford, OX 3 7LD UK
- grid.22937.3d0000 0000 9259 8492Department of Emergency Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Nikolaos Kadoglou
- grid.4991.50000 0004 1936 8948Centre for Statistics in Medicine, NDORMS, University of Oxford, Windmill Road, Oxford, OX 3 7LD UK
| | - Mariska Leeflang
- grid.7177.60000000084992262Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Rene Spijker
- grid.7177.60000000084992262Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Harald Herkner
- grid.22937.3d0000 0000 9259 8492Department of Emergency Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Marialena Trivella
- grid.4991.50000 0004 1936 8948Centre for Statistics in Medicine, NDORMS, University of Oxford, Windmill Road, Oxford, OX 3 7LD UK
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Nanno T, Kobayashi S, Yoshitomi R, Fujii S, Kajii T, Kohno M, Ishiguchi H, Okuda S, Okada M, Suga K, Yano M. Detection of Active Inflammation Status Around Ventricular Aneurysms in Patients With Cardiac Sarcoidosis. Circ J 2019; 83:2494-2504. [PMID: 31631075 DOI: 10.1253/circj.cj-19-0248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little is known about the pattern of isotope accumulation in the heart on 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography in patients with cardiac sarcoidosis (CS) complicated by ventricular aneurysm (VA).Methods and Results:We prospectively enrolled 82 consecutive patients with CS; 54 patients with active CS (presence of abnormal 18F-FDG accumulation in the heart) were subdivided into VA (n=17) and non-VA groups (n=37). Strong 18F-FDG accumulation surrounding the VA and its disappearance in the VA center was observed in all patients with VA, probably because of scar formation at the VA. Peak standardized uptake value was higher around the VA than in the VA center (5.1±2.1 vs. 2.2±0.6, P=0.0003) and the VA center had no 18F-FDG accumulation (VA center: 2.2±0.6 vs. control area: 2.1±0.6, P=0.37). On the other hand, in non-VA patients with LV wall thinning (n=28), 18F-FDG accumulation was significantly high, even in the area of LV wall thinning (LV wall thinning area: 3.1±0.8 vs. control area: 2.0±0.6, P=0.00002). CONCLUSIONS A pattern of strong 18F-FDG accumulation surrounding the VA and its disappearance in the VA center might be characteristic in patients with CS complicated by VA. Careful attention to FDG uptake would further elucidate CS pathophysiology and aid in the early treatment of VA.
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Affiliation(s)
- Takuma Nanno
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Shigeki Kobayashi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Ryosuke Yoshitomi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Shohei Fujii
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Toshiro Kajii
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Michiaki Kohno
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Hironori Ishiguchi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Shinichi Okuda
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Munemasa Okada
- Department of Radiology, Yamaguchi University Graduate School of Medicine
| | | | - Masafumi Yano
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
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Abstract
The increasing implementation of advanced cardiovascular imaging in the form of cardiac PET/CT has had a significant impact on the management of cardiac sarcoidosis, which continues to evolve. This review summarizes the role of PET/CT imaging in sarcoidosis with a specific focus on (1) indications, (2) patient preparation, (3) test performance, (4) study interpretation, (5) clinical relevance of findings, (6) comparison to alternative imaging modalities, and finally (7) introduction of areas of anticipated development and research.
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7
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Kiko T, Yoshihisa A, Kanno Y, Yokokawa T, Abe S, Miyata-Tatsumi M, Misaka T, Oikawa M, Kobayashi A, Ishida T, Takeishi Y. A Multiple Biomarker Approach in Patients with Cardiac Sarcoidosis. Int Heart J 2018; 59:996-1001. [PMID: 30101857 DOI: 10.1536/ihj.17-695] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease including heart (cardiac sarcoidosis, CS). It has recently been reported that isolated CS, which presenting primarily cardiac symptoms without clinical evidence of sarcoid involvement in other organs. Diagnostic and prognostic biomarkers of CS, especially in isolated CS, have not yet been established.We studied plasma levels of angiotensin-converting enzyme (ACE), soluble interleukin-2 receptor (sIL-2R), B-type natriuretic peptide (BNP) and cardiac troponin I (cTnI) in consecutive 172 patients with diagnosed sarcoidosis. We compared these markers between non-cardiac sarcoidosis (non-CS, n = 123, 71.5%) and CS patients (n = 49, 28.5%), including non-isolated CS (n = 30, 17.4%) and isolated CS (n = 19, 11.1%). ROC analysis revealed that BNP identified CS with AUC of 0.85 (P < 0.01) in sarcoidosis patients. In addition, ACE and sIL-2R levels were significantly higher in non-isolated CS than in isolated CS (P < 0.05). Furthermore, in the Cox proportional hazard analysis, cTnI, but not ACE, IL2R or BNP, was a predictor of fatal arrhythmia in sarcoidosis patients (HR 2.418, P = 0.003).Higher ACE and sIL2-R are associated with systemic lesions, whereas BNP is a useful marker for detecting cardiac involvement in sarcoidosis patients. cTnI is a predictor of fatal arrhythmia in CS patients. A multiple biomarker approach supports comprehensive management of sarcoidosis.
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Affiliation(s)
- Takatoyo Kiko
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University.,Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Yuki Kanno
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Satoshi Abe
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Takafumi Ishida
- Department of Cardiovascular Medicine, Fukushima Medical University
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8
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Diagnostic value of quantitative assessment of cardiac 18F-fluoro-2-deoxyglucose uptake in suspected cardiac sarcoidosis. Ann Nucl Med 2018; 32:319-327. [DOI: 10.1007/s12149-018-1250-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
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9
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Petrovic M, Buja LM, Kar B, Colnaric J, Damaraju S, Zhao B, Akkanti B, Radovanovic M, Radovancevic R, Loyalka P, Gregoric ID. Cardiac sarcoidosis presenting as arrhythmogenic right ventricular cardiomyopathy/dysplasia with ventricular aneurysms: a case report. Cardiovasc Pathol 2018; 33:1-5. [DOI: 10.1016/j.carpath.2017.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/04/2017] [Accepted: 11/02/2017] [Indexed: 11/27/2022] Open
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10
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Sipilä K, Tuominen H, Haarala A, Tikkakoski A, Kähönen M, Nikus K. Novel ECG parameters are strongly associated with inflammatory 18 F-FDG PET findings in patients with suspected cardiac sarcoidosis. Int J Cardiol 2017; 249:454-460. [DOI: 10.1016/j.ijcard.2017.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/30/2017] [Accepted: 07/06/2017] [Indexed: 01/05/2023]
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11
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Ishiguchi H, Kobayashi S, Myoren T, Kohno M, Nanno T, Murakami W, Oda S, Oishi K, Okuda S, Okada M, Suga K, Yano M. Urinary 8-Hydroxy-2′-Deoxyguanosine as a Myocardial Oxidative Stress Marker Is Associated With Ventricular Tachycardia in Patients With Active Cardiac Sarcoidosis. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006764. [DOI: 10.1161/circimaging.117.006764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/31/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Hironori Ishiguchi
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Shigeki Kobayashi
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Takeki Myoren
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Michiaki Kohno
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Takuma Nanno
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Wakako Murakami
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Seiko Oda
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Keiji Oishi
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Shinichi Okuda
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Munemasa Okada
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Kazuyoshi Suga
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
| | - Masafumi Yano
- From the Division of Cardiology, Department of Medicine and Clinical Science (H.I., S.K., T.M., M.K., T.N., W.M., S. Oda, K.O., S. Okuda, M.Y.) and Department of Radiology (M.O.), Yamaguchi University Graduate School of Medicine, Ube, Japan; and Department of Radiology, St Hill Hospital, Ube, Japan (K.S.)
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Yong WC, Sanguankeo A, Upala S. Association between sarcoidosis, pulse wave velocity, and other measures of subclinical atherosclerosis: a systematic review and meta-analysis. Clin Rheumatol 2017; 37:2825-2832. [DOI: 10.1007/s10067-017-3926-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/13/2017] [Accepted: 11/17/2017] [Indexed: 12/29/2022]
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13
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Lopez-Candales A, Hernandez-Suarez DF. Strain Imaging Echocardiography: What Imaging Cardiologists Should Know. Curr Cardiol Rev 2017; 13:118-129. [PMID: 27799029 PMCID: PMC5452148 DOI: 10.2174/1573403x12666161028122649] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/06/2016] [Accepted: 10/18/2016] [Indexed: 01/30/2023] Open
Abstract
Despite recent advances in clinical imaging, echocardiography remains as the most accessi-ble and reliable noninvasive. Since knowledge of left ventricular systolic function remains so critically important in determining prognosis; every effort should be made to prevent subjective estimations. The advent of strain imaging echocardiography now offers a readily available and portable imaging tool that not only offers an objective characterization of myocardial dynamics; but also allows for early detection of subclinical left ventricular dysfunction. This review outlines the basic concepts of strain imaging to better understand the mechanism of myocardial function as well their applicability in the least common cardiac diagnosis among current clinical practice.
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Affiliation(s)
- Angel Lopez-Candales
- Cardiovascular Medicine Division, University of Puerto Rico School of Medicine, Medical Sciences Building, PO Box 365067, San Juan, Puerto Rico
| | - Dagmar F Hernandez-Suarez
- Cardiovascular Medicine Division, University of Puerto Rico School of Medicine, Medical Sciences Building, PO Box 365067, San Juan, Puerto Rico
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14
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Te ALD, Lin YJ, Chen YY, Chung FP, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Lin CY, Chang YT, Chien KL, Chen SA. Increased risk of ventricular tachycardia in patients with sarcoidosis during the very long term follow-up. Int J Cardiol 2017; 228:68-73. [DOI: 10.1016/j.ijcard.2016.11.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/03/2016] [Accepted: 11/05/2016] [Indexed: 12/22/2022]
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15
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Shelke AB, Aurangabadkar HU, Bradfield JS, Ali Z, Kumar KS, Narasimhan C. Serial FDG-PET scans help to identify steroid resistance in cardiac sarcoidosis. Int J Cardiol 2017; 228:717-722. [DOI: 10.1016/j.ijcard.2016.11.142] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
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16
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Durand M. Cardiovascular MRI of the pericardium: A case review of the anatomy, scan protocols and pathology of the pericardium. SA J Radiol 2016. [DOI: 10.4102/sajr.v20i2.1022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The aim of this article was to present a case based review of the anatomy, scan protocols and pathology of the pericardium. Cardiovascular magnetic resonance imaging provides excellent anatomic depiction of the pericardium, vital information on myocardial infiltration and characterisation of mass lesions and pericardial effusions. It adds valuable information in the assessment of complicated pericardial disease.
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17
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Al-Kofahi K, Korsten P, Ascoli C, Virupannavar S, Mirsaeidi M, Chang I, Qaqish N, Saketkoo LA, Baughman RP, Sweiss NJ. Management of extrapulmonary sarcoidosis: challenges and solutions. Ther Clin Risk Manag 2016; 12:1623-1634. [PMID: 27853374 PMCID: PMC5106225 DOI: 10.2147/tcrm.s74476] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Sarcoidosis is a chronic multisystem disease of unknown etiology characterized by noncaseating granulomas that most often involves the lungs, but frequently has extrapulmonary manifestations, which might be difficult to treat in individual patients. Objective To review different disease manifestations, focusing on extrapulmonary organ systems, and to provide treatment options for refractory cases. Materials and methods We performed a literature search using Medline and Google Scholar for individual or combined keywords of “sarcoidosis, extrapulmonary, treatment, kidney, neurosarcoidosis, cardiovascular, gastrointestinal, transplantation, musculoskeletal, rheumatology, arthritis, and skin”. Peer-reviewed articles, including review articles, clinical trials, observational trials, and case reports that were published in English were included. References from retrieved articles were also manually searched for relevant articles. Results and conclusion Isolated involvement of a single organ or organ system is rare in sarcoidosis, and thus all patients must be thoroughly evaluated for additional disease manifestations. Cardiac sarcoidosis and neurosarcoidosis may be life-threatening. Clinicians need to assess patients comprehensively using clinical, laboratory, imaging, and histopathological data to recommend competently the best and least toxic treatment option for the individual patient.
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Affiliation(s)
- Khalid Al-Kofahi
- Department of Molecular Biosciences, University of Kansas, Lawrence, KS, USA
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL
| | | | - Mehdi Mirsaeidi
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Ian Chang
- Department of Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, MI
| | - Naim Qaqish
- Department of Gastroenterology, Hepatology and Nutrition, University of Buffalo, Buffalo, NY
| | - Lesley A Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Robert P Baughman
- Department of Medicine, University Medical Center of Cincinnati, Cincinnati, OH, USA
| | - Nadera J Sweiss
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL; Division of Rheumatology, University of Illinois at Chicago, Chicago, IL
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Abstract
Treatment of sarcoidosis is not required in all patients with the diagnosis. The decision to treat and the strategy for how to treat usually require input and shared decision making by the patient. Some common consequences of sarcoidosis are not caused by granulomatous inflammation, but may be the dominant disease manifestation and should be actively considered when formulating a treatment plan. The medication regimen should be tailored to each patient. Steroid-sparing medications should be prescribed early as part of a long-term strategy.
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Affiliation(s)
- Marlies S Wijsenbeek
- Department of Pulmonary Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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19
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Myoren T, Kobayashi S, Oda S, Nanno T, Ishiguchi H, Murakami W, Okuda S, Okada M, Takemura G, Suga K, Matsuzaki M, Yano M. An oxidative stress biomarker, urinary 8-hydroxy-2'-deoxyguanosine, predicts cardiovascular-related death after steroid therapy for patients with active cardiac sarcoidosis. Int J Cardiol 2016; 212:206-13. [PMID: 27043062 DOI: 10.1016/j.ijcard.2016.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/19/2016] [Accepted: 03/12/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated whether urinary 8-hydroxy-2'-deoxyguanosine (U-8-OHdG), a marker of oxidative DNA damage, is a prognosticator of cardiovascular-related death in patients with cardiac sarcoidosis (CS). METHODS AND RESULTS In this prospective study, 30 consecutive patients were divided into the active CS (n=20) and non-active CS (n=10) groups, based on abnormal isotope accumulation in the heart on (18)F-fluorodeoxyglucose positron-emission tomography/computed tomography ((18)F-FDG PET/CT) imaging. Nineteen patients in the active CS group underwent corticosteroid therapy. Before corticosteroid therapy initiation, U-8-OHdG, brain natriuretic peptide (BNP), other biomarkers, and indices of cardiac function were measured. Patients were followed-up for a median of 48months. The primary endpoint was the incidence of cardiovascular-related death. During the follow-up period, in the corticosteroid-treated active CS group, 7 of 19 patients experienced cardiovascular-related death. By contrast, in the non-active CS group, 1 of 10 patients died from cardiovascular-related causes. Univariate and multivariate analyses showed that U-8-OHdG and BNP were independent predictors for cardiovascular-related death. The cut-off values for predicting cardiovascular death in corticosteroid-treated patients with active CS were 19.1ng/mg·Cr and 209pg/mL for U-8-OHdG and BNP, respectively. Patients with a U-8-OHdG concentration ≥19.1ng/mg·Cr or a BNP concentration ≥209pg/mL had a significantly higher cardiovascular-related death risk, but U-8-OHdG had better predictive value compared with BNP. CONCLUSION These findings suggested that U-8-OHdG was a powerful predictor of cardiovascular-related death in patients with CS, suggesting that active CS patients with elevated U-8-OHdG levels might be resistant to corticosteroid therapy.
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Affiliation(s)
- Takeki Myoren
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Shigeki Kobayashi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan.
| | - Seiko Oda
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takuma Nanno
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Hironori Ishiguchi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Wakako Murakami
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Shinichi Okuda
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Munemasa Okada
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Genzou Takemura
- Department of Internal Medicine, Asahi University School of Dentistry, Mizuho, Japan
| | | | - Masunori Matsuzaki
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Masafumi Yano
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
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Nagai T, Nagano N, Sugano Y, Asaumi Y, Aiba T, Kanzaki H, Kusano K, Noguchi T, Yasuda S, Ogawa H, Anzai T. Effect of Discontinuation of Prednisolone Therapy on Risk of Cardiac Mortality Associated With Worsening Left Ventricular Dysfunction in Cardiac Sarcoidosis. Am J Cardiol 2016; 117:966-71. [PMID: 26805658 DOI: 10.1016/j.amjcard.2015.12.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 11/24/2022]
Abstract
Prednisolone (PSL) therapy is the gold standard treatment in patients with cardiac sarcoidosis (CS). However, clinicians often have difficulty in deciding whether to discontinue PSL therapy in long-term management. Sixty-one consecutive patients with CS were divided into 2 groups based on the discontinuation of PSL during the median follow-up period of 9.9 years. PSL was discontinued in 12 patients because of improvement of clinical findings. There were no significant differences between the 2 groups in age, gender, left ventricular ejection fraction (LVEF), findings of imaging techniques, incidence of fatal arrhythmias and heart failure, and dose of PSL. After discontinuation of PSL, 5 patients had cardiac death, and discontinuation of PSL was significantly associated with higher cardiac mortality compared with continuation (p = 0.035). Although patients with discontinuation had improvement of LVEF after PSL treatment, LVEF decreased after discontinuation of PSL. Furthermore, discontinuation of PSL was associated with greater percent decrease in LVEF compared with continuation (p = 0.037) during the follow-up period. In conclusion, in the long-term management of patients with CS, discontinuation of PSL was associated with poor clinical outcomes and decreased LVEF, suggesting the importance of PSL maintenance therapy.
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Abdelhamid MA, Diab HS. The arrhythmic burden in patients with sarcoidosis. Is it a real concern? EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2016. [DOI: 10.1016/j.ejcdt.2015.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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22
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Mehta D, Willner JM, Akhrass PR. Atrial Fibrillation in Cardiac Sarcoidosis. J Atr Fibrillation 2015; 8:1288. [PMID: 27957226 DOI: 10.4022/jafib.1288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/04/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease that affects the myocardium. Although ventricular arrhythmias are well known manifestations of cardiac involvement, there is increasing evidence that a significant proportion of patients with cardiac sarcoidosis (CS) also have atrial arrhythmias, atrial fibrillation being the most frequent. The incidence and mechanism of atrial fibrillation in CS is not precisely known. The management of atrial fibrillation in patients with CS is currently done according to the general guidelines for management of atrial fibrillation. Evidence is emerging regarding the additional role of immunosuppression for the treatment of atrial arrhythmias in CS. This paper reviews the incidence, possible mechanisms and treatment strategies of atrial fibrillation in patients with CS.
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Affiliation(s)
- Davendra Mehta
- Division of Cardiology, Mount Sinai St Luke's Hospital, New York, NY 10025
| | - Jonathan M Willner
- Division of Cardiology, Mount Sinai St Luke's Hospital, New York, NY 10025
| | - Philippe R Akhrass
- Division of Cardiology, Mount Sinai St Luke's Hospital, New York, NY 10025
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Bois JP, Chareonthaitawee P. Radionuclide Imaging in Congestive Heart Failure: Assessment of Viability, Sarcoidosis, and Amyloidosis. Cardiol Clin 2015; 34:119-32. [PMID: 26590784 DOI: 10.1016/j.ccl.2015.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Radionuclide imaging provides both established and emerging diagnostic and prognostic tools to assist clinicians in the management of patients with ischemic cardiomyopathy, cardiac sarcoidosis, and cardiac amyloidosis. This review highlights the underlying pathophysiology of each entity and associated diagnostic and clinical challenges, and describes the available radionuclide imaging techniques. Specific protocols, advantages and disadvantages, comparison with other noninvasive imaging modalities, and discussion of the evolving role of hybrid imaging are also included.
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Affiliation(s)
- John P Bois
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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24
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Dubrey SW, Sharma R, Underwood R, Mittal T. Cardiac sarcoidosis: diagnosis and management. Postgrad Med J 2015; 91:384-94. [PMID: 26130811 DOI: 10.1136/postgradmedj-2014-133219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 06/12/2015] [Indexed: 12/19/2022]
Abstract
Cardiac sarcoidosis is one of the most serious and unpredictable aspects of this disease state. Heart involvement frequently presents with arrhythmias or conduction disease, although myocardial infiltration resulting in congestive heart failure may also occur. The prognosis in cardiac sarcoidosis is highly variable, which relates to the heterogeneous nature of heart involvement and marked differences between racial groups. Electrocardiography and echocardiography often provide the first clue to the diagnosis, but advanced imaging studies using positron emission tomography and MRI, in combination with nuclear isotope perfusion scanning are now essential to the diagnosis and management of this condition. The identification of clinically occult cardiac sarcoidosis and the management of isolated and/or asymptomatic heart involvement remain both challenging and contentious. Corticosteroids remain the first treatment choice with the later substitution of immunosuppressive and steroid-sparing therapies. Heart transplantation is an unusual outcome, but when performed, the results are comparable or better than heart transplantation for other disease states. We review the epidemiology, developments in diagnostic techniques and the management of cardiac sarcoidosis.
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Affiliation(s)
- S W Dubrey
- Department of Cardiology, Hillingdon Hospital, Uxbridge, UK
| | - R Sharma
- Department of Cardiology, The Royal Brompton Hospital, London, UK
| | - R Underwood
- Department of Radiology, Harefield Hospital, Harefield, UK
| | - T Mittal
- Department of Radiology, Harefield Hospital, Harefield, UK
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25
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Abstract
Myocardial involvement in patients with sarcoidosis can be difficult to diagnose, and requires a high index of suspicion and low threshold for screening. The presentation of cardiac sarcoidosis is variable, and can range from asymptomatic electrocardiographic changes to sudden cardiac death. This review provides an overview of the arrhythmic consequences of cardiac sarcoidosis, with emphasis on the electrophysiologist's role in recognition, diagnostic testing, and management of this rare disease.
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Affiliation(s)
- Matthew M Zipse
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, 12401 East 17th Avenue, B132, Aurora, CO 80045, USA
| | - William H Sauer
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, 12401 East 17th Avenue, B132, Aurora, CO 80045, USA.
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26
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Nagai T, Nagano N, Sugano Y, Asaumi Y, Aiba T, Kanzaki H, Kusano K, Noguchi T, Yasuda S, Ogawa H, Anzai T. Effect of Corticosteroid Therapy on Long-Term Clinical Outcome and Left Ventricular Function in Patients With Cardiac Sarcoidosis. Circ J 2015; 79:1593-600. [PMID: 25877828 DOI: 10.1253/circj.cj-14-1275] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cardiac involvement is the worst prognostic determinant in patients with sarcoidosis, but the long-term prognostic significance of corticosteroid therapy for cardiac sarcoidosis (CS) remains unclear. METHODS AND RESULTS We examined 83 consecutive patients diagnosed with CS. Patients were divided into 2 groups based on the presence or absence of corticosteroid therapy at diagnosis. Patients with corticosteroid therapy had lower age and higher rate of positive findings in the myocardium on gallium scintigraphy (Ga) at diagnosis than those without. LVEF, biomarkers, and use of cardiovascular medication were similar between the 2 groups. During the follow-up (7.6±4.4 years), corticosteroid therapy was associated with fewer long-term adverse events (overall, P=0.005; cardiac death, P=0.92; symptomatic arrhythmias, P=0.89; heart failure admission, P<0.0001) and a greater % increase in LVEF than those without (7.9±36.3% vs. -16.7±34.8%, P=0.03). On Cox proportional hazards modeling, corticosteroid therapy (HR, 0.41; 95% CI: 0.20-0.89) was an independent determinant of long-term adverse event-free survival, but age, sex, LVEF, and Ga findings were not. CONCLUSIONS Corticosteroid therapy might have a beneficial effect on long-term clinical outcome in CS patients, particularly by reduction of heart failure admission and retarding the progression of LV systolic dysfunction.
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Affiliation(s)
- Toshiyuki Nagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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27
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Wicks EC, Menezes LJ, Elliott PM. Improving the diagnostic accuracy for detecting cardiac sarcoidosis. Expert Rev Cardiovasc Ther 2015; 13:223-36. [DOI: 10.1586/14779072.2015.1001367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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28
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Isobe M. [The Cutting-edge of Medicine; Clinical features of isolated cardiac sarcoidosis]. ACTA ACUST UNITED AC 2015; 104:120-7. [PMID: 26571786 DOI: 10.2169/naika.104.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Isobe M, Tezuka D. Isolated cardiac sarcoidosis: clinical characteristics, diagnosis and treatment. Int J Cardiol 2014; 182:132-40. [PMID: 25577749 DOI: 10.1016/j.ijcard.2014.12.056] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/12/2014] [Accepted: 12/21/2014] [Indexed: 02/07/2023]
Abstract
Sarcoidosis is a systemic disease characterized by the development of noncaseating epithelioid granulomas in multiple organs. Despite extensive investigations over a long period of time, the etiology of this disease remains unknown. Cardiac involvement of this disease is the most ominous complication leading to fatal outcome. Recently, attention has been focused on isolated cardiac sarcoidosis, which exists without clinically apparent sarcoidosis elsewhere. One of the critical issues of isolated cardiac sarcoidosis is difficulty in diagnosis, since existence of the cardiac lesion should be detected from cardiac manifestations alone. Because specificity of biomarkers or sensitivity of histological examination of biopsied sample is very low, diagnosis of isolated cardiac sarcoidosis mainly depends on imaging modalities. In this review article we summarized current knowledge on the pathogenesis of sarcoidosis, clinical features of cardiac sarcoidosis especially that isolated to the heart by showing some typical cases. Utilities and problems of diagnostic imaging tests for this condition including echocardiography, cardiac magnetic resonance imaging, and fluorodeoxyglucose-positron emission tomography are discussed. Advances in pharmacological and nonpharmacological treatment for cardiac sarcoidosis have improved the prognosis of cardiac sarcoidosis to a great deal; however, there are many issues that remain to be solved in the management of isolated cardiac sarcoidosis.
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Affiliation(s)
- Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan.
| | - Daisuke Tezuka
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan
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30
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Clinical characteristics of definite or suspected isolated cardiac sarcoidosis: application of cardiac magnetic resonance imaging and 18F-Fluoro-2-deoxyglucose positron-emission tomography/computerized tomography. J Card Fail 2014; 21:313-22. [PMID: 25512195 DOI: 10.1016/j.cardfail.2014.12.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 11/27/2014] [Accepted: 12/04/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Isolated cardiac sarcoidosis (iCS) is difficult to diagnose in patients without histologic evidence of sarcoidosis. We aimed to clarify the clinical characteristics of iCS, including imaging features on cardiac magnetic resonance imaging (MRI) and (18)F-fluoro-2-deoxyglucose positron-emission tomography/computerized tomography (FDG-PET/CT) scans. We also reviewed the therapeutic effect of corticosteroids and determined the long-term prognosis. METHODS AND RESULTS We retrospectively reviewed 83 consecutive patients with suspicious CS from 1997 to 2013. Systemic sarcoidosis with CS (sCS, n = 30) and iCS (n = 11) were diagnosed according to clinical criteria. In iCS cases, sarcoidosis was not detected in any other organs. The clinical features did not significantly differ between sCS and iCS cases, except for ejection fraction, which was lower in iCS (P = .025). Nine sCS and 4 iCS cases showed late gadolinium enhancement, and the lesions tended to be on the epicardial side (76.9% P = .011) and septal wall (52.9% P < .001). The coefficient of variance for the myocardial standardized uptake value of FDG-PET/CT was higher in sCS (0.32 ± 0.13; n = 19) and iCS (0.32 ± 0.09; n = 7) than in control cases (n = 31; P < .001). B-Type natriuretic peptide level was improved after prednisolone treatment in both groups. Kaplan-Meier curve indicated that prognosis was not different between sCS and iCS cases. CONCLUSIONS The clinical cardiac characteristics of iCS cases were similar to those of sCS. Cardiac MRI and FDG-PET, noninvasive imaging modalities, could be useful modalities to detect myocardial involvement in the cases with definite or suspected iCS.
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Sehgal VN, Riyaz N, Chatterjee K, Venkatash P, Sharma S. Sarcoidosis as a systemic disease. Clin Dermatol 2014; 32:351-63. [DOI: 10.1016/j.clindermatol.2013.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nureki SI, Miyazaki E, Nishio S, Ehara C, Yamasue M, Ando M, Kadota JI. Interventricular septal thickening as an early manifestation of cardiac sarcoidosis. Int Heart J 2014; 55:181-3. [PMID: 24632961 DOI: 10.1536/ihj.13-243] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report an unusual case of cardiac sarcoidosis demonstrated by interventricular septal thickening. A 64-year-old woman was diagnosed with sarcoidosis involving the lungs, eyes, and skin. Three years later, renal dysfunction was detected during a periodic examination and a renal biopsy revealed non-caseating granulomas. Electrocardiogram results were normal, but an echocardiogram revealed thickening of the interventricular septum. Abnormal accumulation of gallium-67 and a perfusion defect in tecnetium-99-methoxyisobutylisonitrile scintigrams occurred in the interventricular septum. Magnetic resonance images showed T2-high intensity in the lesion. We considered the thickening to represent cardiac involvement of sarcoidosis. Oral prednisolone therapy diminished the interventricular septal thickening.
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Affiliation(s)
- Shin-ichi Nureki
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
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Tezuka D, Isobe M. [Cardiomyopathy: progress in diagnosis and treatments. Topics: II. Secondary cardiomyopathy; 2. Cardiac sarcoidosis]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:299-308. [PMID: 24724370 DOI: 10.2169/naika.103.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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36
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Spectrum of physiological and pathological cardiac and pericardial uptake of FDG in oncology PET-CT. Clin Radiol 2012. [PMID: 23177651 DOI: 10.1016/j.crad.2012.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cardiac uptake of 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) is frequently observed on FDG positron-emission tomography combined with computed tomography (PET-CT) performed for diagnosis, staging, and assessment of therapeutic response of lymphoma and solid cancers, despite careful patient preparation to limit myocardial glucose substrate utilisation. We illustrate the varied physiological patterns of cardiac FDG uptake, and show a spectrum of pathological conditions causing FDG uptake within myocardial and pericardial structures, due to clinically important benign and malignant diseases. Recognition and awareness of these various causes of FDG uptake in the heart, along with the appropriate use of correlative contrast-enhanced CT and magnetic resonance imaging (MRI) will facilitate correct interpretation.
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Akashi H, Kato TS, Takayama H, Naka Y, Farr M, Mancini D, Schulze PC. Outcome of patients with cardiac sarcoidosis undergoing cardiac transplantation--single-center retrospective analysis. J Cardiol 2012; 60:407-10. [PMID: 22890069 DOI: 10.1016/j.jjcc.2012.07.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 06/20/2012] [Accepted: 07/04/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Controversy exists whether heart transplantation (HTx) is an appropriate treatment option for patients with cardiac sarcoidosis due to its potential recurrence and multi-organ involvement. Recent data from the United Network for Organ Sharing dataset suggest that the clinical outcome of cardiac sarcoidosis patients is equivalent or even better than that of the general HTx population. METHODS We retrospectively reviewed the clinical course of 14 patients with cardiac sarcoidosis among a total of 825 patients who underwent HTx at Columbia University Medical Center between 1997 and 2010. Post-transplant survival of patients with sarcoidosis was compared with that of non-sarcoidosis patients. RESULTS More than half of cardiac sarcoidosis patients were initially diagnosed after HTx by tissue analysis of the explanted heart. While only 2/14 cases showed recurrence of cardiac sarcoidosis, the clinical outcome of sarcoid patients showed a trend toward higher mortality than that of non-sarcoidosis patients following HTx (1- and 5-year survival, 78.5 versus 87.2%, 52.4 versus 76.2%, respectively, p=0.09). CONCLUSIONS Although this is a single-center, retrospective analysis of a small number of cardiac sarcoidosis patients who underwent HTx, a concerning trend toward a higher mortality of patients with cardiac sarcoidosis was noted. A careful candidate selection in patients with known cardiac sarcoidosis should be discussed.
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Affiliation(s)
- Hirokazu Akashi
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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Dastoori M, Fedele S, Leao JC, Porter SR. Sarcoidosis - a clinically orientated review. J Oral Pathol Med 2012; 42:281-9. [DOI: 10.1111/j.1600-0714.2012.01198.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2012] [Indexed: 01/15/2023]
Affiliation(s)
- Mahmoud Dastoori
- Department of Maxillofacial Medicine and Surgery; Oral Medicine unit; UCL Eastman Dental Institute; London; UK
| | - Stefano Fedele
- Department of Maxillofacial Medicine and Surgery; Oral Medicine unit; UCL Eastman Dental Institute; London; UK
| | | | - Stephen R. Porter
- Department of Maxillofacial Medicine and Surgery; Oral Medicine unit; UCL Eastman Dental Institute; London; UK
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41
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Chapelon-Abric C. Cardiac sarcoidosis. Presse Med 2012; 41:e317-30. [DOI: 10.1016/j.lpm.2012.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 04/03/2012] [Accepted: 04/03/2012] [Indexed: 12/27/2022] Open
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Ardic I, Yarlioglues M, Dogdu O, Buyukoglan H, Kanbay A, Akpek M, Bol C, Yuksel M, Akkaya E, Vuruskan E, Kaya MG. Assessment of aortic elastic properties in patients with sarcoidosis. Blood Press 2012; 21:286-92. [DOI: 10.3109/08037051.2012.656397] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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UCHIDA MIO, SHINOHARA TETSUJI, TAKAHASHI NAOHIKO, SAIKAWA TETSUNORI. Interventricular Septal Mass in a Patient with Cardiac Sarcoidosis. J Cardiovasc Electrophysiol 2011; 23:433-5. [DOI: 10.1111/j.1540-8167.2011.02227.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kandolin R, Lehtonen J, Graner M, Schildt J, Salmenkivi K, Kivistö SM, Kupari M. Diagnosing isolated cardiac sarcoidosis. J Intern Med 2011; 270:461-8. [PMID: 21535250 DOI: 10.1111/j.1365-2796.2011.02396.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Cardiac sarcoidosis (CS) without clinically apparent extracardiac disease may escape detection because of the poor sensitivity of endomyocardial biopsy (EMB). We set out to analyse our experience of repeated and imaging-guided biopsies in clinically isolated CS. METHODS We retrospectively reviewed the medical records, laboratory test results, imaging studies and pathological analyses of 74 patients with either histologically proven or clinically probable CS at our institution between January 2000 and December 2010. RESULTS Fifty-two patients had histologically proven CS, of whom 33 (26 women) had disease that was clinically isolated to the heart. Sarcoidosis was detected in the first EMB in 10 of the 31 patients who underwent biopsy. CS was found by repeated EMBs, targeted by cardiac imaging, in seven additional patients, and 11 patients were diagnosed by sampling 18-F-fluorodeoxyglucose position emission tomography-positive mediastinal lymph nodes at mediastinoscopy. Together, the first biopsy (cardiac or mediastinal lymph node) provided the diagnosis in 34%, the second biopsy in 31% and the third in 22% of biopsied patients with isolated CS. Four (13%) of the remaining diagnosis were made after cardiac transplantation and one in a patient who did not undergo biopsy) at autopsy after sudden cardiac death. CONCLUSIONS Cardiac sarcoidosis may present without clinically apparent disease in other organs. At least two-thirds of patients remain undiagnosed after a single EMB session. The detection rate can be improved by repeated and imaging-guided cardiac or mediastinal lymph-node biopsies. Nevertheless, false-negative biopsy results remain a problem in CS patients with no apparent extracardiac disease.
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Affiliation(s)
- R Kandolin
- Division of Cardiology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Gurm GS, Chirindel A, Chen W. Emerging Role of Fluorodeoxyglucose-PET in the Diagnosis of Cardiac Sarcoidosis. PET Clin 2011; 6:403-8. [DOI: 10.1016/j.cpet.2011.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Sun BJ, Lee PH, Choi HO, Ahn JM, Seo JS, Kim DH, Song JM, Choi KJ, Kang DH, Song JK. Prevalence of echocardiographic features suggesting cardiac sarcoidosis in patients with pacemaker or implantable cardiac defibrillator. Korean Circ J 2011; 41:313-20. [PMID: 21779284 PMCID: PMC3132693 DOI: 10.4070/kcj.2011.41.6.313] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 09/01/2010] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Basal septal thinning or localized aneurysmal dilatation without coronary artery disease has been described as a characteristic finding suggestive of cardiac sarcoidosis. We sought to assess the prevalence of this characteristic echocardiographic finding in patients with pacemaker (PM) or implantable cardiac defibrillator (ICD). SUBJECTS AND METHODS Echocardiography of patients who received PM or ICD were retrospectively analyzed. Patients with marked thinning and akinesia confined to the basal septum (type 1), or posterolateral wall resulting in localized aneurysmal outward bulging (type 2) without history of myocardial infarction or significant coronary stenosis were included for analysis. RESULTS Among 1,357 consecutive patients, 21 exhibited suggestive echocardiographic findings (type 1/2=15/6) with a mean ejection fraction of 37±11%. The prevalence was 1.2% in the PM group and 4.0% in the ICD group. Only 3 patients showed histologically confirmable sarcoidosis in lymph nodes, lung and heart, respectively. Endomyocardial biopsy was attempted in 6 patients, but failed to demonstrate sarcoidosis. The 1-, 2-, 4- and 6-year clinical events (death, cardiac transplantation and hospital admission)-free survival rates were 100%, 85.7±7.6%, 75.0±9.7% and 48.6±12.4%, respectively. During follow-up, two patients with PM underwent ICD implantation, and another underwent heart transplantation. CONCLUSION Prevalence of echocardiographic features suggesting prevalence of cardiac sarcoidosis is low in patients who underwent device implantation. However, considering the very low yield of endomyocardial biopsy and the rare extracardiac manifestations in cardiac sarcoidosis, characteristic echocardiographic findings could be an adjunctive diagnostic criterion in these patients.
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Affiliation(s)
- Byung Joo Sun
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Tahara N, Tahara A, Nitta Y, Kodama N, Mizoguchi M, Kaida H, Baba K, Ishibashi M, Hayabuchi N, Narula J, Imaizumi T. Heterogeneous myocardial FDG uptake and the disease activity in cardiac sarcoidosis. JACC Cardiovasc Imaging 2011; 3:1219-28. [PMID: 21163450 DOI: 10.1016/j.jcmg.2010.09.015] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 09/30/2010] [Accepted: 09/30/2010] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study evaluated the usefulness of fasting (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) in the diagnosis and management of cardiac sarcoidosis (CS) and compared it with FDG uptake in dilated cardiomyopathy (DCM). BACKGROUND Cardiac sarcoidosis may clinically present as DCM but is amenable to systemic corticosteroid therapy if disease activity is high. Although alterations of FDG uptake have been reported in CS, limited information is available on the quantitative estimates of FDG uptake. METHODS Fasting FDG-PET was performed in 24 systemic sarcoidosis patients and was compared with 8 age-matched DCM patients. FDG-PET was also performed in 15 age-matched healthy control subjects. Twelve of the 24 sarcoidosis patients had cardiac involvement based on criteria established by the Japanese Ministry of Health and Welfare; the remaining 12 of 24 patients revealed no evidence of cardiac involvement. The myocardial FDG uptake was quantified by measuring the standardized uptake value in 17 myocardial segments in each subject. Coefficient of variation (COV), which equals the standard deviation of uptake divided by the average uptake of 17 segments, was calculated as an index of heterogeneity in the heart. RESULTS The FDG uptake was distinctly heterogeneous in CS patients. The COV value was significantly greater in CS patients (0.25 ± 0.05) than control subjects (0.14 ± 0.03, p < 0.01), sarcoidosis patients without cardiac involvement (0.14 ± 0.03, p < 0.01), or DCM patients (0.15 ± 0.02, p < 0.01). The COV value in DCM patients was similar to control subjects or sarcoidosis patients without cardiac involvement. The cutoff COV value for the diagnosis of CS was 0.18 (sensitivity: 100%; specificity: 97%). After corticosteroid therapy in CS patients, the COV value was decreased to 0.14 ± 0.06 (p < 0.05) and became essentially similar to the other groups. CONCLUSIONS Heterogeneous myocardial FDG uptake may be a useful diagnostic marker of disease activity for CS.
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Affiliation(s)
- Nobuhiro Tahara
- Department of Medicine, Division of Cardio-Vascular Medicine, Kurume University School of Medicine, Kurume, Japan.
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Unusual cardiovascular manifestations of sarcoidosis, a report of three cases: coronary artery aneurysm with myocardial infarction, symptomatic mitral valvular disease, and sudden death from ruptured splenic artery. Cardiovasc Pathol 2010; 19:e119-23. [DOI: 10.1016/j.carpath.2009.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 03/24/2009] [Accepted: 04/14/2009] [Indexed: 11/18/2022] Open
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Balan A, Hoey ETD, Sheerin F, Lakkaraju A, Chowdhury FU. Multi-technique imaging of sarcoidosis. Clin Radiol 2010; 65:750-60. [PMID: 20696303 DOI: 10.1016/j.crad.2010.03.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 03/16/2010] [Accepted: 03/22/2010] [Indexed: 01/12/2023]
Abstract
Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. The diagnosis is suggested on the basis of wide ranging clinical and radiological manifestations, and is supported by the histological demonstration of non-caseating granulomas in affected tissues. This review highlights the multisystem radiological features of the disease across a variety of imaging methods including multidetector computed tomography (CT), magnetic resonance imaging (MRI) as well as functional radionuclide techniques, particularly 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT). It is important for the radiologist to be aware of the varied radiological manifestations of sarcoidosis in order to recognize and suggest the diagnosis in the appropriate clinical setting.
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Affiliation(s)
- A Balan
- Department of Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Buckley O, Doyle L, Padera R, Lakdawala N, Dorbala S, Di Carli M, Kwong R, Desai A, Blankstein R. Cardiomyopathy of uncertain etiology: Complementary role of multimodality imaging with cardiac MRI and 18FDG PET. J Nucl Cardiol 2010; 17:328-32. [PMID: 19777320 PMCID: PMC3954521 DOI: 10.1007/s12350-009-9145-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Orla Buckley
- Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Boston, MA
| | - Leona Doyle
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Robert Padera
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Neal Lakdawala
- Cardiovascular Division (Department of Medicine), Brigham and Women’s Hospital, Boston, MA
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Boston, MA
- Cardiovascular Division (Department of Medicine), Brigham and Women’s Hospital, Boston, MA
| | - Marcelo Di Carli
- Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Boston, MA
- Cardiovascular Division (Department of Medicine), Brigham and Women’s Hospital, Boston, MA
| | - Raymond Kwong
- Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Boston, MA
- Cardiovascular Division (Department of Medicine), Brigham and Women’s Hospital, Boston, MA
| | - Akshay Desai
- Cardiovascular Division (Department of Medicine), Brigham and Women’s Hospital, Boston, MA
| | - Ron Blankstein
- Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Boston, MA
- Cardiovascular Division (Department of Medicine), Brigham and Women’s Hospital, Boston, MA
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